The Smoking Gun

Andy Austin

Launched in a blaze of publicity Prozac has rapidly become the drug of choice for the medical treatment of `depression` with the number of prescriptions exceeding all expectations.

The diagnostic criteria of depression has expanded tremendously over the last ten years and a new breed of teenagers, fed on pop psychology and 'yoof culture' are being prescribed Prozac. Following the suicide of cult rock singer Kurt Cobain, depression has taken on a fashionable quality, spawning a number of contemporary non fiction paperbacks expounding the joys of being depressed in a technological age. A whole new 'yoof culture' has evolved, embracing dangerous living, amphetamine logic and a kind of depressive rebellion, each member proudly waving their "I'm a victim, so It`s not my fault" flag.

It`s not just the 'yoof' that are benefiting from Prozac, prescription in the elderly has exceeded all expectation and has rapidly become the drug of choice for elderly depression. Popping one little capsule a day isn't too taxing for those who blindly obey their God-like doctor figures and take two little red ones, a yellow one and a water tablet in the morning, one little round one, another little red one and a heart tablet at lunchtime and God-only-knows-what in the evening. It also has the added benefit of not buggering up the heart rhythm (as potentially do the old anti-depressants) in a elderly person with a dodgey ticker.

Prozac is the trade name belonging to the pharmaceutical company Dista for the chemical Fluoxetine Hydrochloride.

Fluoxetine was the first of a new class of anti-depressant drugs colloquially known as Selective Serotonin Re-uptake Inhibitors (SSRI). Later there were other SSRI`s such as Lustral (Sertraline), Seroxat (Paroxetine) and Faverin (Fluvoxamine Maleate).

These chemicals are believed to 'work' by affecting a specific neuro-transmitter in the brain, Serotonin, preventing its natural re-uptake from nerve synapses (from where having completed its job will be oxidised and de-activated by mono-amine oxidase) and thereby increasing the amount of Serotonin available for use by the brain.

The principal behind this is the medical belief that low Serotonin levels produces depression. Serotonin is believed to be the brain chemical related to emotion and feelings. However this relationship is somewhat indirect. Whilst low Serotonin levels are found in the brains of autopsied suicide victims, a low Serotonin level does not result in an immediate experience of depression and does not produce this effect in everyone.

It is thus likely that Serotonin mediates another system that is slower to change in order to produce noticeable effects. This suggestion comes from the observably delayed therapeutic effect of 2-6 weeks, even though Serotonin levels can be at maximum level after just a few hours of taking an antidepressant.

The previously used anti-depressants like the mono-amine oxidase inhibitors (MAOI`s) such as Nardil (Phenelzine), Marplan (Isocarboxazid) and Parnate (Tranylcypromine) produced a similar effect by blocking the production of the substance (MAO) that de-activated the neuro-transmitter. These drugs however can be extremely toxic in combination with certain foods and other drugs, and are rarely used nowadays.

The tricyclic antidepressants such as Amitriptyline and Imiprimine are less toxic in prescribed dosages but are sedating and very dangerous in overdosage, producing marked cardiac problems especially when taken in overdosage with alcohol. This has previously presented quite a dilemma for doctors when prescribing a dangerous drug to the very people most likely to use it for deliberate overdose.

Both MAOI`s and Tricyclic`s have many side effects such as dry mouth, sedation, constipation, difficulty passing urine, postural hypertension, rapid pulse, fainting, sweating, behavioural changes, hypomania, confusion, blood sugar changes and interference with sexual activity. This list does not include the potential liver effects and haematological effects. Most of the side effects arise from the drugs effects on the other neurotransmitter systems, particularly the muscarinic systems.

Prozac, launched in a flurry of media publicity was believed to overcome these problems by targeting only the serotonergic system. Following its successful trials in the treatment of previously difficult to treat depressions such as 'atypical' and 'masked' depressions. Relatively side effect free it rapidly gained popularity around the world and became the drug of choice for the treatment of depressive illness.

In overdosage Fluoxetine in comparatively safe and can be prescribed in combination with the neuroleptic drugs used to treat psychosis. (Neuroleptics such as chlorpromazine and haloperidol lower levels of another transmitter, dopamine, which is believed to be raised in 'schizophrenia'.) This became ideal in bio-psychiatry where many schizophrenics also experience concomitant depression, either due to their 'schizophrenic illness' or their social environment, or as a side effect of the drugs used to 'treat' the allegedly psychotic illness.

Prozac itself went from being 'relatively free from side effects' in 1989 to having side effects such as nausea, vomiting, diarrhoea, anorexia with weight loss, headache, nervousness, insomnia, anxiety, tremor, dry mouth, dizziness, hypomania, drowsiness, convulsions, fever, sexual dysfunction, sweating, as well as blood disorders, in 1992 listing in the BNF text.

Following the media sensation of Prozac the backlash developed with several lawsuits being brought against Dista with alleged criminals claiming they were acting under the influence of Prozac with claims of: "it-wasn't-me-it-was-the-drug-that-made-me-do-it." Prozac`s image changed to became a 'controversial drug' with several instances of defence cases resting on the suggestion of Prozac in some way being responsible none of which have ever been upheld. These cases maintained the ongoing publicity for Prozac and thus continued to raise tremendously the expectations of the drug.

Whilst it is readily acknowledged that the way a doctor presents a drug to his patient, the drugs name, package and colour will affect the patient's experience of the drug; in the case of Prozac, the doctor needs not apply such placebo. Patients already know what drug they want before they even see their doctor, reports abound of patients visiting their doctors and demanding their right to Prozac.

Having been "Drug of the Year" on the front page of Time magazine and with claims of it making its taker "feel better than well" as well its reported ability to perform a 'personality facelift', to act as a 'yuppie upper', the 'Power of Prozac' has become well established as a revolutionary cultural phenomenon.

Not too surprisingly in the United States, Prozac survivors groups emerged, claiming this and that and adding to the media 'controversy'. The Scientology group jumped the bandwagon too (or as Peter Kramer put it, "came out whooping") trying to champion the cause of the anti-Prozac movement. Scientology is inherently against bio-psychiatry and the therapeutic vandalism wrought on the minds and brains of psychiatric patients. As a result its members favour its own 'unique' methods of Dianetic 'auditing', some would say with similar results.

Great claims were made for the positive effects of Prozac. It has been claimed that it can transform personality, ironing out personality deficits and flaws. Some doctors and psychiatrists (notably in the States) take the drug themselves because it makes them feel 'better than well' even though they originally lacked the symptoms of depression. American psychiatrist Peter Kramer wrote a best selling book Listening To Prozac about Prozac`s positive effects, making such claims for it that if I didn't know better I would probably still want it myself.

A particular problem of anti-depressants is highlighted by 'anti-psychiatrist' Peter Breggin with the artificial rise in a neurotransmitters from the effect of anti-depressants. A change in one neurotransmitter cannot occur without affecting the brains own delicate homeostatic mechanisms. Changes in the brain's chemistry in response to an antidepressant can allegedly lead to a permanent drug induced depression on discontinuation of the drug. A 'rebound' depression or withdrawal syndrome of the drug (antidepressants are not 'addictive' but sudden cessation can produce serious problems) may be interpreted as the depression being of organic origin, proof of the necessity of drugs, 'evidence' readily ceased by biopsychiatrists and pharmaceutical companies.

As a therapist, colleagues are reporting difficulties in working with clients who are concurrently taking Prozac (or another SSRI) or other drugs (notably the Neuroleptics) at the time of therapy. It appears that the drug might 'inhibit' therapy and renders the individual unable to change the endogenous psychic factors that produced his depression. I have been unable to find any research to support this idea and would be grateful for any ideas or experience of this alleged phenomena. Personally though, I find when treating a seriously depressed patient with significant cognitive retardation, Prozac or a similar anti-depressant can expedite therapy tremendously.

Medical philosophy might suggest that this effect is because depression is a biological disorder, not a psychic problem. However a discontinuation of the drug leads into a state whereby effective and lasting therapy can occur.

In 1973 American psychiatrist, Ronald Fieve, suggested that lithium salts be administered to several million people as an anti-depressant. It would lower crime, poverty and general unhappiness, it was suggested. Whilst this might seem like something out of an Orwellian future as a chemical method of societal control, it turns out to be unnecessary. With the direction society has taken, rather than work towards a societal change, we have welcomed Prozac with open arms as a solution to our psychic ails. With 1984 past (sic), we embrace our rations of Soma in the Brave New World.

Meanwhile some elderly residents in care are routinely accustomed to finding their coffee tasting a bit odd. The medical and nursing professions are only too happy to slip in a little pill here and there to make life a little easier. We see a person unhappy and desire to make them happy. Prozac provides an easy answer. It is the belief of Survivors that social change is necessary to prevent us being medicated into an Orwellian future, a future we may well welcome.

There is supposedly no withdrawal problems with SSRI`s but an increasing amount of evidence suggests the contrary. I myself experienced some most peculiar sensations such as the room spinning, giddiness, light headedness, mild confusion and extreme swings of mood for about two weeks on discontinuing the drug after just four months. I had been quite excited about taking Prozac, keen to experience the "better than well" feeling. I didn't. Instead I just got a little nauseated and had trouble focusing my eyes. I can't really say if I felt better or not, I certainly felt a little disappointed.